EMCOL Tax & Insurance

Are either of you incarcerated (detained or Jail) Yes – No Are either of you naturalized or derived citizens? (Means born outside the U.S)YesNo

Enter the Name

Alias

IMMIGRATION STATUS (Check what apply)

US CITIZENS

RESIDENT CARD # A-

CERTIFICATE #

TPS CARD #

WORK PERMIT CARD #

Relationship/ Tax/ EmploymentMarriedSingle

DependentsYesNo

How many

MedicardYesNo

Do you plan to file a federal income tax for 2017?YesNoSeparatedJointly

Does anyone have the same home address and currently live in Florida?YesNo

Are you a Full time student?YesNo

No, # of dependents in tax return

Are you currently working?YesNo

Self-employedYesNo

UnemployedYesNo

SSI

Amount $/month

Are you responsible for a child 18 or younger who lives with you, but isn’t on your tax return? YesNo

SPOUSE INFORMATION

First Name

Middle Name

Last Name

SSN

Date of Birth

US Citizens

Green Card

TPSYesNo

Certificate number

Are you a full time student?YesNo

DEPENDENTS INFORMATION

1.Full Name

Date of Birth

SSN

Relationship

Citizen YesNo

SexMaleFemale

2.Full Name

Date of Birth

SSN

Relationship

Citizen YesNo

SexMaleFemale

3.Full Name

Date of Birth

SSN

Relationship

Citizen YesNo

SexMaleFemale

4.Full Name

Date of Birth

SSN

Relationship

Citizen YesNo

SexMaleFemale

APPLICANT EMPLOYMENT INFORMATION

Company's Name

Company's Phone Number

Company's Address

Salary Rate $

Hourly $

Monthly $

Weekly $

Yearly $

Full-timePart-timeTemporary

SPOUSE’S EMPLOYMENT INFORMATION (Actively working)

Company's Name

Company's Phone Number

Company's Address

Salary Rate $

Hourly $

Monthly $

Weekly $

Expected Salary for 2017?

Any dependent actively Working? YesNo

Is this child who Single and 25 or younger? YesNo

Is this your stepchild or grandchild? YesNo

Do they live with parents who’s not on your tax return? YesNo

DEPENDENT’S EMPLOYMENT INFORMATION

Company's Name

Company's Phone Number

Company's Address

Salary Rate $

Hourly $

Monthly $

Weekly $

Yearly $

Full-timePart-timeTemporary

COVERAGE AND BILLING INFORMATION

Company Selected

Monthly Cost Premium $

Clients Monthly Premium $

Plans:SingleCoupleFamilySub-family

Less Total Subsidy $

Coverage Start Date

CREDIT CARD INFORMATION

Credit Card Number

Expiry Date

CVV

Name on Card

CHECKING ACCOUNT DETAILS

Name on account

Routing#

Account#

By singing this application I hereby certify that the information above are true and accurate and I give the agent below the full authorization to sign my application electronically and enroll me in a qualified health plan through the

Marketplace

Type name

CONTACT
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